Fertility Docs Uncensored Today’s episode of Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, Understanding Decreased Ovarian Reserve, the doctors take a deep dive into what decreased ovarian reserve means and how it can impact fertility treatment and family-building decisions. The episode begins with a discussion of how ovarian reserve is evaluated and why several different tests are used together to provide a more complete picture. The docs explain the roles of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol levels, anti-Müllerian hormone (AMH), and antral follicle count (AFC), and how these factors interact in assessing a woman’s remaining egg supply. The hosts then define decreased ovarian reserve and discuss factors that may increase a woman’s risk, including smoking, prior chemotherapy exposure, and inherited conditions such as Fragile X premutation’s. The conversation also focuses on treatment options and why fertility specialists often recommend a more proactive approach for patients with decreased ovarian reserve. The doctors explain that a lower egg count does not always mean poor egg quality, particularly in younger women, but it can mean that time is an important factor. They review treatment strategies ranging from ovulation induction and intrauterine insemination (IUI) to in vitro fertilization (IVF), and discuss realistic expectations for IVF outcomes. While patients with decreased ovarian reserve may produce fewer eggs during treatment, many can still achieve successful pregnancies with appropriate care and individualized treatment plans. This episode is sponsored by IVF Florida.

Episode Transcript:

Susan Hudson MD (00:01.752)

Hello everyone. This is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs and Censored. Fertility Docs uncensored. I am here with my amazing, beautiful, courageous co-host, Dr. Carrie Bediant from Fertility Center of Las Vegas. And Dr. Abby Evelyn from Nashville Fertility Center. How are y’all doing?

Carrie Bedient MD (00:27.312)

How are you?

Susan Hudson MD (00:28.76)

Doing good, doing good. It’s summertime. It’s lovely. Is it super hot outside where y’all are yet?

Abby Eblen MD (00:37.053)

Hot but not so humid for us, which is great.

Carrie Bedient MD (00:40.947)

How are the mosquitoes where you are, Abby? Especially cause normally the humidity attracts them, right?

Abby Eblen MD (00:47.163)

Yeah, normally ’cause it rained a bunch. Usually the mosquitoes are really bad, but actually they haven’t been horrible lately. For whatever reason, I’m sure they’ll eventually hatch out and be terrible. But for right now they’re pretty good.

Carrie Bedient MD (00:56.873)

I think it’s because they’re vacationing in Las Vegas because Yeah.

Abby Eblen MD (00:59.677)

Probably.

Susan Hudson MD (01:00.032)

I think they’re in Texas too. Yeah. They’re they’re like little vipers right now.

Carrie Bedient MD (01:11.239)

I take the dog out and kind of sit in a corner of my yard while I’m waiting for her to finish her thing and like I have bug bites everywhere. I found a bug bite right in the middle of my butt yesterday. I’m like, this is ridiculous. Like, How did you get into my shorts to that degree? Like I am offended.

Abby Eblen MD (01:27.667)

Does the desert have mosquitoes and bugs? I thought the desert was hot and dry and bugs don’t like that.

Carrie Bedient MD (01:33.669)

So mosquitoes generally don’t, but the Airis Egypti, I’m not saying that right, but the main mosquito that causes all of the big nasty diseases has adapted itself to survive in a very, very tiny amount of water. And so Life will find a way, and mosquitoes have found a way out here. So not only do we have the usual assortment of scorpions, tarantulas, black widows, and other delightful little creatures, but now we have the flying mosquitoes.

Abby Eblen MD (02:01.149)

Wow. That sucks, yeah. Mosquitoes are awful.

Susan Hudson MD (02:04.077)

That’s miserable.

Carrie Bedient MD (02:05.649)

Yeah. Rude. Utterly rude.

Susan Hudson MD (02:10.712)

So how much like I always know that they said that if you have a certain blood type, they attract mosquitoes. Is that actually based on any type of scientific evidence or is that just one of those things that people say?

Abby Eblen MD (02:24.505)

Think so. It’s weird though. I I have I’m O positive, but I I I don’t know if that makes a difference or not. But for some reason, and it may be that my skin is really thin or but if there’s a hundred people in a room and there’s one mosquito, it’ll bite me and I’m not sure why. It’s just weird. It’s so weird.

Susan Hudson MD (02:40.674)

I think mosquitoes are attracted to me, but chiggers or red bugs red bugs are totally attracted to my husband. Like The safest place to go if you’re walking through weeds is right behind him because none of them will get you and all of them will get him.

Abby Eblen MD (02:58.791)

Yeah, see we have to worry walking through grass, we have to worry about ticks and Rocky Mountain spotted fever and Lyme disease and all that. So I try and stay out of any tall grass with anybody.

Susan Hudson MD (03:08.876)

Yeah, we just we have a lot of deer, so even though our grass may be short, you’re still g they still have chiggers. So we don’t have as many ticks. I I I I remember ticks more being an issue when I was a kid than I do now.

Abby Eblen MD (03:15.624)

But there’s some lone star tick that’s supposed to be really pathogenic and I’m assuming based on its name, it probably is Texas bred. You guys sent our way, I think.

Susan Hudson MD (03:32.438)

Yeah, yeah. No, I mean the ticks definitely are out there when my family goes camping, everybody has to, you know, check all the places, make sure that that isn’t an issue. Exactly. Exactly.

Abby Eblen MD (03:41.363)

All the warm places that it takes good land.

Carrie Bedient MD (03:47.431)

Never thought that I would be appreciative of scorpions and tarantulas. But y’all have just made me appreciative of scorpions and tarantulas that don’t go hiding in the dark places. And like, are leeches a thing? Are leeches a thing for either of you guys?

Abby Eblen MD (04:07.782)

Leeches? No. Well, you know, actually, yeah, in our rivers we do have a few leeches. I’ve never seen one, but I’ve heard people like actually yeah, I know in our rivers we do ’cause I know somebody that had a leech on Apparently they’re pulled off really easily though. But that’d be pretty good.

Susan Hudson MD (04:21.006)

I think there are some in r in rivers, but not to a huge degree. Like you could be like a serious water sports, like in there a lot type of thing.

Abby Eblen MD (04:24.496)

Yeah, not huge.

Abby Eblen MD (04:31.376)

Yeah. This wasn’t where the conversation was supposed to go, but hey.

Carrie Bedient MD (04:31.763)

Susan, do we have a question? ‘Cause I don’t like this topic anymore.

Susan Hudson MD (04:36.258)

We do have a question for today.

It all works. It all works. Okay. Our question for today is I did three IUIs last year. The third one resulted in a miss miscarriage at eight weeks. I did a fourth one in September and a fifth one in November. I decided to wait until the new year to force fertility coverage and my last one failed in February. Since it’s number six, they want to regroup. I was really hoping to have three in a row, February, March, and April, but now I can’t.

I’m afraid they won’t let me try anymore. I do have two older kids and two miscarriages these last couple years. I really don’t want to do IVF. I just want this to work.

Susan Hudson MD (05:23.212)

So what are your thoughts?

Carrie Bedient MD (05:25.395)

So is it more of a question of three in line or just will three more work? What do we think?

Abby Eblen MD (05:33.008)

I think it’s more she just doesn’t want to do IVF and she’s hoping and crossing fingers and toes that everything else will work even though she’s done it for six or seven times.

Carrie Bedient MD (05:41.673)

She didn’t tell us how old she was, did she?

Susan Hudson MD (05:43.534)

She did not.

Abby Eblen MD (05:43.73)

She has two older two older kids though.

Carrie Bedient MD (05:45.959)

Yeah. So it’s not that doing IUIs seven, eight, and nine will never work. It’s just

Statistically, it’s less likely to. I just saw a study that came out, I don’t know if it was in Fert and Stert or one of the other journals, but it was talking about success rates up to I think IUI number eight. And it showed that they were still reasonable. It’s just in many cases the that only takes can you get pregnant into account? Not necessarily. What is the probability? How much more likely is IVF to work at that stage? And then it sure doesn’t take into account all of the emotional and financial and other parts of this world, those components that really play a role in it because Well, yes, there will be a subset of people who do get pregnant on seven, eight, and nine. Most people, by the time they get to that point, are absolutely fried. They’re financially not necessarily getting help from insurance anymore. Or if they are, it means that they’re it’s eating away at their benefit for something like IVF that has a stronger success rate ratio. And so It’s a it’s a balance of whether or not it really makes a difference. If you know you’re never gonna do IVF, then sure, go ahead. But but it’s just it’s that balance of what really makes sense to do given your end goals. And all of us have seen people who have done

Carrie Bedient MD (07:20.463)

IUIs forever and it and it doesn’t work, or they are just so emotionally depleted that by the time they do come back to do IVF, it it’s five years later and now their chances have plummeted because of normal passage of time.

Abby Eblen MD (07:35.41)

Yeah, and would say reading between the lines, she has two older kids. She had three IUIs, then had a miscarriage and has done several more. And, you know, kind of piggybacking onto what you said, the other issue is, you know, if you’re 38, 39, 40, you know, maybe you might get pregnant and maybe it might be a healthy embryo. But statistically, even if you get pregnant again, 50% of the time when people have miscarriages, it’s due to a genetic abnormality, may even be probably higher based on your age. And so You probably know from the last miscarriage it takes you out of trying for several months until, you know, you miscarry and things get back to normal with your endometrium. And so I would agree with Carrie, you know, it’s probably not going to hurt you if IVF is never going to be an option for you. But I would say at least talk to your doctor about it and get more details about it. It may not be as overwhelming as you think it is. You might have some coverage and you know that would be something to look at as well.

But probably you’re gonna have better success if you move on to IVF at this point.

Susan Hudson MD (08:38.176)

One thing I do want to mention is there was this mention of three in a row. And and I want to kind of clarify from our standpoint, When we talk about IUIs and recommending two or three IUIs, that’s generally because your momentum is growing in that first, second, third IUI. And after that, success rates relatively plateau. It again, it doesn’t mean you can’t get pregnant, but you’re really not having any growing momentum at that point.

And so A lot of REIs will have a general guideline, not a rule, but a general guideline that three is usually the point that we need to sit down and chat, talk about other options, see what we need to do, see if there’s any additional testing, anything else like that that’s going on. And there’s not anything magical about doing three back to back. It it it Three is three, whether you do two last year and one this year or one for one year at a time or However, it happens, three is three. And so Sometimes I have patients who come in who think that it’s like, I have to do three in a row, or that’s the only way that it works is three in a row. And that’s really not the case. If you need to take a break for whatever reason, I mean, obviously time is never our friend, which will segue us into kind of our main topic for today, but realize that that that three in a row is just three IUI cycles. All right. Okay. Well today we are going to talk about diminished ovarian reserve. So first of all, what exactly is diminished ovarian reserve?

Abby Eblen MD (10:25.201)

Really just a low egg count. it doesn’t mean necessarily that the eggs that you have are bad and that’s been can that’s always confusing to patients. It just means that if you look at women that are your age and kind of look at the average number for somebody your age, you have a lower amount of eggs. You have your gas tank’s half full or lower.

Susan Hudson MD (10:44.534)

Now would somebody can you have quality issues and that also be considered diminished ovarian reserve?

Abby Eblen MD (10:51.697)

You can. You can also have quality issues. Anything that kind of impairs your ability to be like your peers, essentially.

Susan Hudson MD (10:59.766)

Okay. And what are the major measures of ovarian reserve? How somebody’s ovaries are working?

Carrie Bedient MD (11:09.661)

When we’re looking at ovarian reserve, the there are the three measurable things that we can do in terms of testing. And then there’s the fourth, just automatic consideration. So the three testable things that when you go into an REI’s office, they’re gonna start looking at. The first one is AMH. This is a lab test, very, very helpful because you can draw it at any time. And so It doesn’t really make a difference where you are in your cycle if you’re having cycles versus having IUD or PMOS where you’re not ovulating, things like that. And it’s looking at the relative amount of eggs that you have in deep storage.

And so we’re looking, does this level hit a low, medium, or high amount? And that gives us a relative idea of do you have very little, average, or a lot of eggs in there? And in general, we’re hoping to see a level of 1.5 or greater. But how we interpret that depends on if you’re 40 years old, I don’t expect you to have a level of 1.5. In fact, I’m delighted if you have a level of one. Versus if you are 30 years old, really you probably ought to have a level of at least Two to three, and and it’s that balance. But like all these tests, the AMH level, you don’t live and die by it. It’s just one piece of information that’s coming in. Another, I’ll go ahead, somebody else take another one, because otherwise it’ll be the media monologue for the next half an hour.

Susan Hudson MD (12:41.902)

So another thing that we look at is FSH. And FSH is a hormone that the brain produces that stimulates the ovaries, and estradiol is what the ovaries produce that feeds back to the brain. Now, when we do this FSH level, we do generally want to do it between cycle day one to four. If you are someone who ovulates on a regular basis, if you’re somebody who doesn’t ovulate on a regular basis, there’s a little more leeway in that. And FSH is not quite as cut and dry as AMH is. There’s a more disagreement of what’s normal, what’s abnormal, how strong of a value is it? However, I think most of us would agree that an FSH less than 10 is normal. Something between 10 and 18 is concerning, and over 18.

Very, very, very concerning. I’ll leave that. I’ll leave it at that. Abby, what’s another measure of ovarian reserve?

Abby Eblen MD (13:51.268)

So FSH, LH is another measure of ovarian reserve. Often we see if FSH is L elevated, so is LH. And One thing about FSH too, sometimes we can see people that sort of go in and out of kind of having regular cycles. And sometimes the months where people have tend to have regular cycles, even if they’ve been told they have decreased ovarian reserve, we check those hormones and they’re good, particularly in younger women.

We don’t see that as much in older women. And I think the other issue with FSH too is if it’s consistently higher, that kind of tells us this has probably been a problem that’s been going on for quite some time. It’s not something that just happened, you know, few months ago. The brain has kind of caught up and realized that the egg count’s low and that the estrogen’s low.

Susan Hudson MD (14:39.598)

Can you tell us a little bit about antral follical count?

Abby Eblen MD (14:43.485)

So antral follical count is something that we look at on ultrasound. On ultrasound, we hope to see lots of little tiny baby eggs. So people kind of get confused. These baby eggs, sometimes people confuse with pathologic cysts, and they’re not pathologic cysts. They’re little just tiny eggs on your ovaries. Generally, if you have a really high amount of antral follicles, that gives us some suggestion that you may have a condition like polycystic ovary syndrome, which has now been renamed to polyendocrine metabolic. Yeah. It’s kind of a mouthful, but named probably better now than it was before. So too much is not necessarily bad, but it does lend does make us think that you may have that. A low number, I would say, and it’s really dependent on the age of the patient, but overall, if I see a young woman who has less than four to five per ovary, I’m a little bit worried about that.

Carrie Bedient MD (15:14.673)

Metabolic ovarian syndrome.

Susan Hudson MD (15:15.158)

metabolic ovarian syndrome.

Abby Eblen MD (15:41.453)

And like Carrie said, when somebody’s around forty or s or beyond, we don’t expect to see a lot of antral follicles. If we do, that’s great, but you know, it’s just that’s part of kind of a the aging process. We tend to see less follicles in the ovaries.

Susan Hudson MD (15:56.718)

Carrie, you mentioned another criteria, not something that we necessarily measure per se, but what’s that other criteria that can fall into concerns about diminished ovarian reserves?

Carrie Bedient MD (16:08.521)

That’s your birthday. And we’re not talking about zodiac signs here. So it doesn’t matter if you’re a Virgo versus a Gemini as to what we think about your eggs. There’s no judgment there. But it is how long ago you were born because eggs have been there our entire lives. Women are born with everything they’re going to get. And you start off with maybe six to seven million when you’re halfway through pregnancy before you’ve emerged into the world. By the time you get out into the world, you’ve got about one to two million. When you hit puberty, it’s roughly 300 to 500 thousand.

 And then when you hit menopause, which the average age in the US is about 51, that’s got a couple hundred to a thousand left. And so if we have someone who is 29, that means that her eggs have only been hanging around for the better part of 30 years. As opposed to someone who’s 40, all of a sudden you’re talking about 41 years, and that That interval makes a huge difference because there’s no mechanic that is boiling the hinges, tuning things up within the ovaries. And that applies to the eggs as well. So they’ve just been sitting there. And in the same way that you wouldn’t take a car that’s been sitting in your garage for a couple of years and assume that the first time you go to turn it on, it’s going to work absolutely beautifully with no hitches. If you’ve got eggs that have been sitting there for 40 years, it’s a lot more likely that when you go to turn the key and and get them started that it’s not going to work out quite the same way. And so It doesn’t mean that it can’t. It just means when you’re playing the odds, there’s a much higher likelihood that you’re going to want to backup mode of transportation for the car that’s been sitting in the garage for 41 years.

And and so that’s That’s we look at age. So If we’ve got someone who comes in, if she’s 42, even if she is model beautiful, the epitome of health and absolutely perfect in every way with nutrition and exercise and mental health and sleep and every single habit, her age still plays a part because they have been sitting there and there’s no mechanic in there putting WD-40 on the hinges.

Susan Hudson MD (18:16.216)

So other than biologic age, what are some other things that we as REIs, our little spidey senses, start getting a little more concerned about may, hey, maybe ovarian reserve may be an issue. What are some things that we could know about this individual that may make us more concerned about how her ovaries may be working?

Abby Eblen MD (18:41.341)

Well, one that comes to mind right off the bat is if she’s had some exposure to chemotherapy, that certainly can be an issue. Anything that damages the eggs, ’cause like Carrie said, we have one set of eggs and essentially once that one set of eggs is damaged, there’s really nothing we can do about that. And that’s why a lot of times we’ll have young women come to see us before they get chemotherapy so that we can freeze their eggs and they can use them in the future.

Carrie Bedient MD (19:07.111)

History of smoking is a big one. It is one of the most modifiable risk factors. If someone’s getting chemo, it’s usually because they didn’t have a choice. Nobody just goes out on a Saturday night and says for fun, hey, let’s get some chemotherapy. Smoking is a modifiable one. And it is one of the very definitive factors that people can control that influences age of menopause.

And so If someone’s got a history of smoking, even if they’re not smoking right now, in the past, we know that those eggs have seen a little bit more of an insult than if someone is not a smoker.

Susan Hudson MD (19:47.042)

So if we maybe have had a patient who has maybe ovulatory dysfunction like PMOS or somebody who has endometriosis and they have crossed the paths of other physicians in the past, what are what are some things with those types of people that may make us more concerned?

Abby Eblen MD (20:11.548)

So, if patients have had surgery, particularly if they have an endometrioma in the ovary, and endometrioma is a collection of endometriosis that grows in the ovary, that typically means that you have a more advanced version of endometriosis. Often in order to really fix kind of whatever the issue is, like if you’re having pain, generally most physicians, if they’re going to go in surgically and they see an endometrioma, they’re going to want to remove it because you’re just draining it doesn’t really do the job.

So in order to drain it, they have to cut through normal ovarian tissue, they have to dissect out the wall of that sac and pull that cyst out. And endometriosis tends to have lots of blood supply. So It tends to be a fairly vascular surgery, lots of bleeding. And so Oftentimes a physician has to co coagulate or or or get rid of or stop that bleeding. And so In doing so, unfortunately, there’s lots of little eggs in there that may be damaged. And so Many years ago, we used to do that often. Now we do that less often unless the endometrioma is really large, three or four centimeters or greater, or if the patient’s having a lot of pain, we try and leave ovaries alone, particularly before we do IVF, because if we’re going to aspirate eggs, we want to get those out before you have damage from the surgery.

Susan Hudson MD (21:28.056)

So sometimes people with PMOS can have a surgery where essentially they go and burn some of the ovary away to essentially reduce the egg load to encourage more natural monthly cycling. And though it sometimes can work and it’s not done as much in the US as it once was.

I still have some patients who come from other countries on a regular basis that have had this done. And and those are people that that does make me more concerned. What are some other health conditions that make us a little more concerned about ovarian reserve?

Carrie Bedient MD (22:10.985)

There’s a genetic condition called fragile X that we screen for, especially if someone comes in and they are, they have a lower ovarian reserve than what we would anticipate for their age. And fragile X is a genetic condition. And it is an instability in the X chromosome. There’s these little things called repeats, and think of them as the little three-pronged Lego blocks. And instead of having five of them, for example.

these numbers are not true to force but instead of having five of them maybe you’ve got 10 of them or 20 of them and having those little really short blocks in there the more and more you have the more unstable that chromosome is and there are people who have a full-on fragile X syndrome that is related to decreased mental capacity, it’s there’s a movement disorder associated with it. One of the things that can be dissoci associated with it is decreased ovarian reserve. And so Many times people will come in and will be doing these screening tests and they don’t have full on fragile X, but they’ve got what’s called a pre-mutation, where instead of having a huge number of these extra little Lego blocks, they’ve got a moderate number.

And we want a small number. So they don’t have the huge amount. It doesn’t mean that they have the condition. It means that that X chromosome is more unstable. And one of the offshoots of that is having an earlier age at menopause. So when we see that in people, we tend to jump a little bit faster of all right, maybe we want to do a little more fertility preservation, be a little bit more aggressive, think about that second or third child that’s desired now rather than letting it go, even if someone is young and we would otherwise not be terribly concerned about that. In the presence of fragile X mutation or premutation, we pay more attention to that and we’re a little bit more mindful of what can happen in the future because they’re not necessarily on the same timeline as someone who is not affected by that.

Susan Hudson MD (24:16.31)

Also, if you have any autoimmune conditions, the most common reason other than age for us to see somebody with diminished ovarian reserve is that just their ovaries are not acting the right age. And a lot of these people have other autoimmune conditions, whether it’s celiac, graves disease, Hashimoto’s, ulcerative colitis, Crohn’s, psoriasis, to name just a few of them.

But realize that autoimmune disorders travel in packs. And if you have one, you’re at an increased risk for another. So if you have an autoimmune dis disorder, being aware that your ovarian aging may, not always, but it may not go along the normal timeline is is a possibility. So say somebody has diminished ovarian reserve, and say we have We’re we’re just gonna, for simplicity’s sake, say we have mild to moderate ovarian reserve issues. Nothing as an REI doctor we’re super, super sweating about, but you know, we we we see that this is gonna be a little bit of a challenge. How how do you advise those people for this pregnancy and future pregnancies?

Abby Eblen MD (25:36.924)

Well, I think it’s important for women to really kind of know what family size is important for them. And so, you know, Some women are happy with one child, some people want a basketball team. And so, you know, If somebody in that situation wants several pregnancies, her age that she is now is the best her egg reserve is ever going to get. The the older she gets and the more she ages, the less likely she’s gonna have good embryos, good eggs that are genetically normal. And so You know, I think if you’re somebody that just wants one baby, then maybe you don’t have to do anything too aggressive. But I always worry when I see somebody with a low egg reserve because I’m just worried I I don’t know when that process is going to come to completion and when you’re not going to have any more eggs. So often we’ll advise patients who want multiple pregnancies to think about freezing eggs, going through IVF, either creating embryos or freezing eggs for future use, because those eggs or those embryos don’t age, whereas you continue to age.

And Then, you know, if you know you have two or three genetically normal embryos, you may go, That’s great. Maybe my partner and I will try on our own right now and then use those eggs or embryos at a later time.

Susan Hudson MD (26:46.09)

One thing I want to insert is when your REI asks you about how many children you would ideally want to have, I always preface it with in your ideal world, not the world where you’re sitting here talking to me. And it’s because I want, we want you to tell us your your honest truth. Because when we’re coming up with plans and recommendations for you, if you’re one and done, which is completely fine, I’m an only child.

I completely respect that. that’s okay.

Abby Eblen MD (27:17.125)

I would have never known that, Susan. I would have never known you’re an only child.

Susan Hudson MD (27:21.198)

But seriously, if if if you truly only want to have one child, that is completely fine. But don’t don’t tell your REI one when in your heart of hearts you’re thinking two, three, four. Because there’s there’s different things that we’re going to counsel you on. And no one’s ever gonna hold you to it. But it it gives us an idea of if you have diminished ovarian reserve, are we looking at really focusing on this one or do we need to focus on this one and also have some more thoughtful conversations about those future babies?

Carrie Bedient MD (27:59.717)

If you say three and then later change your mind to one, we are not going to we’re not gonna hunt you down and find you and say, look, you promised us two more children. it’s It’s really just kind of getting an idea. You’re totally entitled to change your mind. The other thing about that is when we ask that question, we are not asking how many kids do you want at one time.

Our plan is always one at a time. That is safer for you and safer for baby. And so This is not saying, do you want a singleton twins or triplets? This is saying, do you want baby one, two, and later three? Or are you thinking about just one? Cause sometimes I think people read that question in a different way than we are intending to it intending it.

Susan Hudson MD (28:45.326)

So say somebody comes in and they have pretty bad ovarian reserve and we’re gonna just leave it at that. We’re not gonna attach any numbers to it. okay? And they come in and they’re like, what do I do now? How do you break down the most common treatments? And how do you advise when is the right time to go where?

Abby Eblen MD (29:14.033)

Wow, that’s a big question. I think it’s really dependent on the patient. I mean, as a physician, when I see those numbers, I try not to show panic, but sometimes I feel panicked if the numbers are really low. And, you know, but I But I’ve also seen, and I learned this, you know, over many years, I’ve also seen patients that you think for all the world they have such a low egg count, they’ll never get pregnant and they get pregnant with the first IUI cycle. So you really yeah, you never can say never and you never can predict how somebody’s gonna do. And so I think kind of I lean toward trying to be a little bit trying to encourage in my patients to be a little bit more aggressive, or at least at minimum, if they’re gonna do IUI cycles, let’s do them, even though we talked about earlier you can do them at different times, but let’s do them pretty closely together. Let’s figure out if that’s gonna work or not. If it doesn’t work, then let’s pretty quickly go to something more aggressive that may work more quickly and be more effective.

Susan Hudson MD (30:05.484)

What are some of those more aggressive treatments?

Carrie Bedient MD (30:09.733)

Sometimes when people come in, they are thinking about just doing ovulation induction with plain old clomid. And then the next step up from that is adding trigger medications, monitoring IUI. And the next step up from that is doing maybe an ITI where it’s an intra-tubal insemination. And then the next step up from that is doing IVF, where we’re giving much stronger medications to encourage as many of those little eggs to grow at a time as they can. Not because we want to deplete your entire ovarian supply in one cycle because it doesn’t work like that. But because we want to take advantage of maybe instead of one egg growing, which is what it would do on a natural cycle, we have four or five or nine or ten or whatever number we can get come out all at the same time. Now there will be some patients where when we run the numbers on all of those things, trying to use their own eggs is highly unlikely to work, or will take quite a high number of cycles to do. And some patients say, look, I would love to be able to do 10 cycles of IVF, and that is absolutely not reality. And I have one cycle to do this, whether that is financially, physically, emotionally, because there are plenty of people who may have the bandwidth to do it financially.

But just emotionally, they can’t do it anymore. They’ve already spent five to seven years before they got to us struggling, and they’re not in the market for that particular struggle anymore. And so in those cases, someone may decide to go to a donor egg or donor embryo in order to bypass some of the issues that the eggs may have and and trade on their strengths, which is usually in these cases the uterus and oftentimes general health are totally fine. So decreased ovarian reserve is not necessarily a problem of carrying the pregnancy. Once you get to the pregnancy, it’s totally fine, and they’ve got the same success rates as anybody else who would do well. But getting there is the problem. And so They may decide: I am done with this deal, and give me a donor egg or a donor embryo, and we’re gonna move on and just get pregnant and go from there.

Susan Hudson MD (32:25.304)

Something I want to dive into a little bit deeper that you alluded to. So if I’m gonna go through IVF and hey, I have diminished ovarian reserve and I’m emotionally with it and I have all the finances and you know, life is you know, full full of roses, but my ovaries just are not great right now. If I do multiple IVF cycles, explain to me why am I not using up all my eggs?

Abby Eblen MD (32:53.143)

The reason you’re not using up all your eggs is when we stimulate you, we try to get a year’s worth of eggs in Susan’s word words. We try and get a year’s year’s worth of eggs if we can. Oftentimes, if you have diminished ovarian reserve, low antral follical count, that might be anywhere from one to three, one to five eggs. And so Ultimately, when we start to stimulate you, eggs we think come along in batches, like maybe every two to three months there’s a new batch of eggs. And so When we start to stimulate you, all we’re gonna really stimulate is the batch of eggs that are available to us large enough to kind of take the FSH medicine and start to grow after being exposed to it. So you still have other eggs that may come along in other months that are not available at that time. But we just sort of take advantage of the eggs that would normally be atretic and go away on their own and we hope that we can get them to stimulate to the size where we can actually retrieve a mature egg from them.

Susan Hudson MD (33:48.716)

Okay. If somebody has diminished ovarian reserve or they’re concerned about it because maybe they’re in their upper 30s, early 40s, something like that, what are some of the adjuvant therapies, supplements, other more fringe things that are out there? Like Which things have some data behind them?

Carrie Bedient MD (34:12.147)

CoQ10.

It’s got some data behind it, 400 to 600 milligrams a day. We want you to be on it for at least two to three months if we have that flexibility. We don’t always, but most of these things that we’re talking about, ideally you’re on them for at least two, if not three months, because as Abby was mentioning, that’s the lead up time for these follicles or eggs growing, and we want them to be exposed to whatever we think is beneficial in that time. So if you’re stopping smoking, if you’re taking a supplement, that’s that’s the time frame we’re generally hoping for. Longer is better, but it that’s the minimum that we’re going for. So CoQ10 is a very popular one that you can get over the counter. You do not need a prescription for it. They sell it in every possible place that sells pills, supplements, and even some of the places that don’t sell pills and supplements, they still have them. And And that’s probably the most common one that we hear about.

Susan Hudson MD (35:09.228)

What are some other things out there?

Abby Eblen MD (35:11.613)

So there’s something known as NAD plus. Just like CoQ10 is sort of a longevity supplement, but this was initially marketed as a longevity supplement. It also works in the cytochrome or it works in the mitochondria in the way that CoQ10 does. And it’s not r It’s one that’s kind of low on the radar, but I’ve had more and more patients lately ask me about it. And it works in a different place in the mitochondria as compared to CoQ10. So I you know, I think it’s worthwhile to try that as well. Other things kind of outside of supplements would be things like acupuncture and yoga. And there’s not great data to, you know, there’s not randomized prospective data to really show that acupuncture and yoga are helpful. With acupuncture, you can kind of find studies on either side, but I think at minimum it helps with relaxation, helps decrease your levels of anxiety, which helps get rid of all those hormones that are problematic like cortisol, those stress hormones. Yoga can do similar sorts of things as well. And so I think both of those would be helpful as you’re kind of going through this process too.

Susan Hudson MD (36:14.134)

So I have a question, and I may be like digging myself in a corner here because we don’t personally do much of this at our practice, but any of y’all have any experience with PRP?

Abby Eblen MD (36:28.007)

A little bit. There is no data on that. I have a s there is no data. Richard Scott has actually published a paper on that. There is no data that shows that PRP or platelet rich plasma is helpful. And essentially that’s where you take you spin down your own blood, or they spin down your own blood until you get to a really rich part of the plasma that has growth factors and things like that. In theory, it can either be injected in the ovary, it can be flushed into the uterine cavity.

But either way, there’s not really great data that shows that it’s beneficial and it’s probably pretty expensive.

Carrie Bedient MD (37:01.883)

It’s also invasive, particularly if you’re injecting it into the ovaries, because it’s it’s an egg retrieval cycle in reverse. and there’s potentially you can introduce an infection in there and and you’re introducing something into the ovaries, and if you compromise it in any way, hit vessel, hit whatever.

Then there’s a concern of did I do more damage. And it’s becoming more and more popular. We’re seeing it more often. We’re not just seeing it in the fertility world. If you’ve ever heard of a vampire facial, that’s PRP because you’re taking your own blood, spinning it down, and then they’re re-injecting it usually into the face. And in hopes that it’s going to have a a significant improvement. And I haven’t read the data on that. So I have no comment one way or the other of whether or not it works. No vampire facial for me. But the It’s becoming more and more common. And so We hear about some of our counterparts doing it and it’s one of those things where it just it doesn’t have great data behind it and it’s expensive and there’s more potential risk to it than just taking, let’s say CoQ10 doesn’t do anything. Well, so you’re taking a supplement a day. It’s relatively cheap, it’s relatively easy, and the negative impact is quite small if there is a negative impact.

With something like PRP, it’s more actively invasive. And so The penalty if you do hit one of those small percentages of negative outcome is considerably higher. And so We don’t we don’t do a whole lot of PRP, although there’s certainly plenty of REIs out there who do do it.

Susan Hudson MD (38:38.516)

All right. Any other thoughts about diminished ovarian reserve that we haven’t touched on today?

Abby Eblen MD (38:47.613)

Well, I think it’s just emotionally, it’s a really tough diagnosis, particularly for young women to get because they’re not expecting it. And I think the one thing you should think about is your egg quality is probably really good. It’s just you just don’t have a lot of eggs. And so As I said earlier in the show, you know, I’ve had a few patients that I’ve just been shocked. They do one treatment cycle and boom, they’re pregnant and they have a diminished ovarian reserve. And so I don’t it don’t s Don’t think of it as sort of this isn’t I’m never gonna have a baby that’s biologically my own.

Don’t think of it at that that at all, but I do think that, you know, it needs to be addressed by your physician and and maybe you need to be a little bit more aggressive with kind of treatments because, you know, you don’t have a good pool of eggs.

Carrie Bedient MD (39:30.185)

The other thing that I would like anyone who’s been diagnosed with DOR to do is raise your right hand, repeat after me, this is not my fault.

And you didn’t do anything to cause this. It’s just how you’re wired. And even if every single other person in your family is having a baby into their 40s, but that is not you, you didn’t cause this. You’re not being punished for anything. This is not your fault. And and many people take it personally.

And they think, my gosh, I did something wrong. I did something bad. And the answer is no, you didn’t. You You’re a human and there’s variations among human and you happen to get the short end of that particular trait. And so We make the best of it that we can. And all of us have had people who’ve gotten pregnant without us thinking that that was a very high likelihood and just in the same way that the opposite can happen too. And so This is not your fault. Please have very little, very little hesitation in going to see a therapist, a counselor, somebody who can be objective from the outside that can help you remember that because this is this can be a very hard diagnosis.

Susan Hudson MD (40:49.676)

Very well said. Very well said. All right. Well, to our audience, thank you so much for listening and subscribe to Apple Podcast to have next Tuesday’s episode pop up automatically for you. Also be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Abby Eblen MD (41:08.295)

Visit fertilitydocsuncensored.com to submit specific questions you have and sign up for our email list. Check out our book, the IVF Blueprint at all major booksellers, Amazon, Barnes and Noble at Bookshop.org. Also catch us on Instagram or Facebook for another quick hit of infertility.

Carrie Bedient MD (41:25.157)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we will talk to you soon. Bye!